Deceased
Patricia (Jill) Croxon
Demographics
79y, female
Coroner
Coroner Archer
Date of death
2019-08-05
Finding date
2023-02-15
Cause of death
medication related cardiac arrest (verapamil and propranolol) in a patient with community acquired pneumonia and immunosuppression associated with treatment for rheumatoid arthritis
AI-generated summary
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she had been taking slow release (Cordilox) in the community. A failure to tick a box on the medication chart indicating slow release form, combined with weekend pharmacy closures and the absence of out-of-hours pharmacist oversight, meant the error was not identified before administration. She received six tablets of immediate release verapamil at 8am on 4 August instead of slow release, causing dangerously high serum levels that peaked rapidly and depressed cardiac function alongside propranolol. The coroner made no criticism of individual clinicians but identified systemic issues. Since her death, Canberra Health Services has implemented a digital health record system requiring explicit selection of drug formulation, removed immediate release verapamil from the night cupboard, and expanded ward-based pharmacy services, changes likely to prevent such errors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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